Question 46
A representative of the law firm of Flotsam, Flotsam & Jetsam enters your office one day and serves you with a subpoena. The subpoena requires you to appear in regard to litigation by one of your former patients, a 31-year-old woman who is claiming that your malpractice led to medical expenses, pain, and suffering because she developed invasive cervical carcinoma. She was last seen in your office 10 years ago. She had been your patient for 5 years, receiving Pap smears in 4 of those 5 years. Your records indicate that she had no abnormal Pap smears. After discussion with your malpractice carrier's attorney, which of the following conclusions is most appropriate?
A The patient should have continued to return for yearly Pap smears
B You are at fault in this case and should avoid a trial
C The laboratory to which the Pap smears were sent is at fault for missing abnormal cells
D Nothing anyone could have done would have prevented this carcinoma
E The patient's health insurer is at fault for not covering the full cost of Pap smear testing
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(A) CORRECT. It is unlikely that a signficicant lesion will be missed in four Pap smears, which is the reason for annual Pap smears. The natural history of the progression from dysplasia to invasive carcinoma is a decade or more, so there is plenty of time to make a diagnosis and treat conservatively. Cervical carcinoma is a preventable condition.
(B) Incorrect. You have not seen the patient for 10 years, during which time a lesion had plenty of time to develop.
(C) Incorrect. It is highly unlikely that abnormal cells would be missed in four Pap smears.
(D) Incorrect. Invasive cervical carcinomas are potentially preventable through Pap smear screening and simple observation on pelvic examination.
(E) Incorrect. Policies vary markedly, but this is an inexpensive test worth getting regardless of the coverage.
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Question 47
A quality assurance (QA) project is done by a group of physicians staffing an outpatient clinic to study rates of false negative Pap smears. The QA project reveals that one physician has accounted for half of all the false negative Pap smears collected by the group over the prior year, when compared to follow-up testing. The physician's collection techniques are analyzed. Of the following procedures practiced, which is the only one that is appropriate?
A Wrote the patient's name on the slides
B Air-dried the slides prior to shipping
C Used lubricant on the speculum during collection
D Scheduled the patient visit during the menstrual phase of her cycle
E Advised the patient to douche the day prior to the appointment
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(A) CORRECT. The Pap smear is a very useful test if performed properly. Patient identification is key to any laboratory testing procedure.
(B) Incorrect. Once the cells are smeared on the slide, it must be fixed quickly to avoid air-drying artefact, which interferes with interpretation.
(C) Incorrect. Any lubricant will interfere with collection and interpretation of the specimen.
(D) Incorrect. Patients should be instructed to schedule an appointment to collect a Pap smear when they are not in the menstrual phase of the cycle.
(E) Incorrect. Patients should be advised not to douche, as this interferes with the Pap test.
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Question 48
A 30-year-old infertile woman has had episodic lower abdominal and pelvic pain for 2 years. A physical examination, including pelvic exam, reveals no abnormalities. A Pap smear shows only a few trichomonads and no dysplastic cells. A laparoscopy is performed, and the gynecologist notes the presence of several blue to red 0.2 to 0.4 cm slighted raised lesions scattered on the pelvic peritoneum in the cul-de-sac and broad ligaments. Which of the following is the most likely diagnosis?
A Metastatic adenocarcinoma
B Neisseria gonorrheae infection
C Endometriosis
D Candidiasis
E Leiomyomata
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(C) CORRECT. These 'powder burns' are typical for the small hemorrhagic foci of endometriosis on pelvic peritoneum that can produce so much discomfort for their size.
(A) Incorrect. Metastases should produce mass lesions, and she would become severly debilitated after several years with an extensive carcinoma.
(B) Incorrect. Gonorrheal infections can produce salpingitis that can be severe, but it usually resolves in several weeks, though pelvic inflammatory disease can continue to produce pain. There is scarring, but no focal red or blue lesions.
(D) Incorrect. Yeast infections involve the vagina, producing discharge and local irritation.
(E) Incorrect. Leiomyomata can be large enough to cause pelvic discomfort, but they are firm masses.
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Question 49
A 43-year-old woman has noted menstrual periods that have been exceptionally heavy, lasting 6 to 8 days, for 4 months. She has also noted minor intermenstrual bleeding. On physical examination her uterine cervix appears normal, and a Pap smear shows no abnormal cells. Pelvic examination reveals that the uterus is enlarged to twice normal size and is nodular. There are no adnexal masses. Which of the following is the most likely diagnosis?
A Endometrial carcinoma
B Leiomyomata
C Ectopic pregnancy
D Endometriosis
E Secondary syphilis
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(B) CORRECT. The most common tumor of the uterus is a leiomyoma. They can be multiple and can lead to abnormal bleeding.
(A) Incorrect. An endometrial carcinoma does not greatly enlarge the uterus. They are most common in postmenopausal women.
(C) Incorrect. An ectopic pregnancy is most likely to occur in the fallopian tube, leading to a small mass that ruptures and bleeds, producing a medical emergency.
(D) Incorrect. Endometriosis consists of small foci no more than a few millimeters in size.
(E) Incorrect. Syphilis can produce a chancre on external genitalia or cervix, but no masses.
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Question 50
A 50-year-old woman has noted increasing abdominal enlargement for the past year. On physical examination, there is a fluid wave, but no tenderness. Bowel sounds are present. She has no vaginal bleeding. An abdominal ultrasound reveals bilateral 10 and 7 cm adnexal masses. At surgery there are bilateral mass lesions of the ovaries. A total abdominal hysterectomy is performed. Pathologic examination of the ovarian masses reveals that they are unilocular, filled with watery fluid, and covered with papillary excrescences on all surfaces. Which of the following neoplasms is this woman most likely to have?
A Granulosa-theca cell tumors
B Mature cystic teratomas
C Fibrosarcoma with metastases
D Serous cystadenocarcinomas
E Clear cell carcinomas
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(D) CORRECT. This is a classic appearance. However, a borderline serous tumor must be distinguished microscopically.
(A) Incorrect. Granulosa-theca cell tumors or fibrothecomas are solid tumors.
(B) Incorrect. Such 'dermoid cysts' are often filled with sebaceous material and lots of hair.
(C) Incorrect. This is rare. Sarcomas are typically large, solid masses.
(E) Incorrect. Clear cell carcinomas of the ovary are usually solid tumors.
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